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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701192
Report Date: 06/16/2026
Date Signed: 06/16/2026 09:44:44 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/11/2026 and conducted by Evaluator Shakaricka Hughes
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260211145020
FACILITY NAME:VITA BELLA ELDERLY CARE IIIFACILITY NUMBER:
342701192
ADMINISTRATOR:SERA NAKALEVUFACILITY TYPE:
740
ADDRESS:6700 SUN RIVER DRTELEPHONE:
(916) 490-0237
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:14CENSUS: 12DATE:
06/16/2026
UNANNOUNCEDTIME BEGAN:
08:38 AM
MET WITH:Facility Staff: Timoci NakalevuTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Staff are forging resident documents.
The Administrator is not present at the facility for a sufficient amount of time.
INVESTIGATION FINDINGS:
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On 06/16/2026 at 8:35 AM, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with the facility staff Timoci and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the above allegations. The current census is 12.

Allegation: Staff are forging resident documents.
It was alleged that staff are forging resident documents. This investigation consisted of resident records review. On 02/13/2026 LPA Hughes conducted a visit to the facility and obtained resident LIC 602 Physician’s Reports for 14 out of 14 residents in care. LPA Hughes reviewed the records and verified that 9 out of 14 LIC 602 Physician’s Reports contained physician signatures. LPA contacted the physician’s offices and confirmed that the signatures on the LIC 602 forms were authentic and consistent with the records maintained by the physicians. There is not enough evidence to corroborate that the facility forged or falsified documents. Therefore, this allegation is unsubstantiated
Continuation 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 27-AS-20260211145020
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: VITA BELLA ELDERLY CARE III
FACILITY NUMBER: 342701192
VISIT DATE: 06/16/2026
NARRATIVE
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Allegation: The Administrator is not present at the facility for a sufficient amount of time.

It was alleged that the Facility Administrator is not present at the facility for a sufficient amount of time. This investigation consisted of interviews with the residents in care and records review. On 2/13/2026 LPA Hughes conducted a visit to the facility, during the visit LPA spoke with 8 out of 14 residents who stated that they are aware of who the facility administrator is, stating that they are always present and available at the facility. Additionally, LPA reviewed facility records LIC 500 Personnel Report which revealed the facility administrator’s presence in the facility. There is not enough information or evidence present to corroborate this allegation therefore the allegation is unsubstantiated.

The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.


SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/11/2026 and conducted by Evaluator Shakaricka Hughes
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260211145020

FACILITY NAME:VITA BELLA ELDERLY CARE IIIFACILITY NUMBER:
342701192
ADMINISTRATOR:SERA NAKALEVUFACILITY TYPE:
740
ADDRESS:6700 SUN RIVER DRTELEPHONE:
(916) 490-0237
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:14CENSUS: 12DATE:
06/16/2026
UNANNOUNCEDTIME BEGAN:
08:38 AM
MET WITH:Facility Staff: Timoci NakalevuTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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The facility allowed excluded individuals to work in the facility.
INVESTIGATION FINDINGS:
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On 06/16/2026 at 8:35 AM, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with the facility administrator Sera and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the above allegations. The current census is 12.

Allegation: The facility allowed excluded individuals to work in the facility.
It was alleged that the facility allowed excluded individuals to work in the facility. This investigation consisted of interviews with residents and facility staff. On 2/13/2026 LPA Hughes conducted a visit to the facility and interviewed four (4) residents. Residents confirmed that excluded individuals (E1) and (E2) were present inside of the facility approximately two weeks prior to the LPA’s visit. Resident (R6) stated that (E1) is the owner of the facility and comes to the facility to collect rental payments from the residents. The facility administrator also acknowledged that (E1) had been present in the facility approximately two months prior to the LPA’s visit.
Continuation 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20260211145020
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: VITA BELLA ELDERLY CARE III
FACILITY NUMBER: 342701192
VISIT DATE: 06/16/2026
NARRATIVE
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Based on interviews conducted during the investigation, sufficient evidence was obtained to support the allegation that excluded individuals were permitted to be present in the facility. This was observed not in compliance with Title 22 regulation 87777(a) Exclusions as the facility did not ensure an excluded individual was not permitted to be present in the facility.


As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted and a copy of the LIC 9099, LIC 9099-D pages and appeal rights were provided to facility. An immediate civil penalty of $500 was assessed during today's visit.
 
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20260211145020
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: VITA BELLA ELDERLY CARE III
FACILITY NUMBER: 342701192
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/17/2026
Section Cited
CCR
87777(a)
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87777 Exclusions (a) The Department may prohibit an individual from serving as a board of directors, executive director, or officer; being employed or allowed in a licensed facility as specified in Health and Safety Code Sections 1569.58 and 1569.59.
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Effective immediately excluded persons will no longer be allowed to be present at a licensed facility.By POC due date, Administrator is to provide CCL with a written plan to ensure that the excluded person will not work, provide services, or interact with any of the residents or staff inside of the facility.
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This requirement was not met as evidenced by:
The facility did not ensure excluded individuals (E1) and (E2) was prohibited from entering the facility. (E1) and (E2) was observed entering the facility on multiple occassions interacting with residents and facility staff.
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An immediate civil penalty of $500 was assessed during today's visit.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5